Monday, August 24, 2009

Before telling this story, I’m going to have to lay some background for my non-medical readers.

The most obscene word in English, in my opinion, has 3 letters and is an acronym. It’s TPA (stands for Tissue Plasminogen Activator).

This drug gets a lot of press as a clotbuster. It has the potential to break down clots and reverse a stroke. That potential, though, has a dark side. By breaking down clots it can also cause catastrophic bleeding into the brain.

So as a result I'm not a fan of this drug. I use it very judiciously, and with a solid understanding by the family and patient of what they are getting into. It can lead to great rewards- and serious complications.

Compounding this is the fact that the drug MUST be given within 3 hours of a defined stroke onset, or the risk of bleeding really goes up. So if I'm told that the symptoms started at 1:45, then a clock immediately starts running, and if the drug isn’t given by 4:45, then it ain’t gonna be. So in that 3 hour window I need to get to ER, confer with the ER doc, assess the patient, get a CT scan and labs, explain the situation and drug (and it’s dangers) to the family/patient, and get their understanding and approval (or refusal) to give it.

So those 3 hours become a very frantic, fast-paced blur. It’s even worse if the patient gets to ER 1 hour after this started, so then I only have 2 hours to work with.

And with that background, I now present “TPA- A Play”, which was performed this weekend at Local Hospital.

Our play opens in ER, where our hero, Dr. Grumpy, has just arrived. The patient is an elderly gentleman with abrupt onset of speech difficulties and right-sided weakness at noon. He got to ER at 1:30, our hero was called at 1:45, and arrived in ER at 2:00. He’s hurriedly examined the patient and met with the wife, and discussed the risks & benefits of TPA.

(Curtain rises)

2:15 p.m. Dr. Grumpy: "What are your thoughts about this treatment, or any other questions?"

Mrs. Smith: "Let me call our children."

Mrs. Smith then whips out a cell phone, frantically calling people all over the country, leaving messages on their voice mail, then calling back to see if they've picked up their voice mail yet. Dr. Grumpy wanders back to nurses' station to review labs.

2:22 p.m. Nurse says wife wants Dr. Grumpy to come discuss this with the patient again. Because of the stroke Mr. Smith is unable to speak or understand speech, but Dr. Grumpy attempts to do so anyway. He reminds Mrs. Smith of the urgency of the situation. She continues to make phone calls. Dr. Grumpy goes back to nurses' station.

2:28 p.m. Mrs. Smith reaches a daughter, and tries to explain situation to her. Then gives cell phone to Dr. Grumpy to explain to daughter.

2:29 p.m. Daughter becomes hysterical and asks to talk to her mother again.

2:31 p.m. Mrs. Smith hands phone to Mr. Smith, and tells him to explain his symptoms to the daughter. The unfortunate stroke patient can’t speak, just stares at phone, saying nothing. Dr. Grumpy leaves the room to keep from breaking down, again reminds wife of urgency.

2:35 p.m. 4 minute attempt to get Mr. Smith to talk to daughter on cell phone ends, with no decision. Highlight was when Mrs. Smith turned up the volume on the cell phone, figuring that might help patient understand daughter better. The look on Mr. Smith's face makes it apparent he's suddenly regretting his choice of spouse.

2:38 p.m. ER volunteer says wife wants Dr. Grumpy to come back and explain to patient for 2nd time what is going on. He good-naturedly attempts to do so. Mrs. Smith repeats everything Dr. Grumpy says, screaming loudly into patients ear, hoping that will help. Dr. Grumpy has a fleeting image of Garrett Morris doing "News for the Deaf" on SNL in 1975. Again reminds wife of urgency.

2:41 p.m. Parents of screaming child in room next door ask Mrs. Smith to stop yelling at Mr. Smith, as it's upsetting their child. She goes into their room to argue with them.

2:44 p.m. Dr. Grumpy goes back to nurses' station, asks staff to play the “Jeopardy!” theme over the loudspeaker.

2:46 p.m. Mrs. Smith somehow decides that the reason she can only reach voice mails is because the cell phone reception inside the hospital is poor.

2:47 p.m. Dr. Grumpy goes back to see if Mrs. Smith has made a decision. Discovers she’s absent from room.

2:49 p.m. Dr. Grumpy and nurses stand at window, incredulously watching Mrs. Smith walk across the street and get in line at a Starbucks, still frantically dialing phone numbers.

2:55 p.m. Mrs. Smith gets a coffee and starts coming back to ER. She walks in front of an oncoming ambulance, which slams on it's brakes and swerves to avoid flattening her. Mrs. Smith goes over and pounds on the driver's side window to cuss out the driver, arguing with him in the middle of the street.

2:58 p.m. Mrs. Smith attempts to enter ER again through ambulance entrance, which only opens for a paramedic or hospital ID. She frantically knocks and waves at the paramedic who she just finished cussing out. They get into another argument about which of them needs to pay better attention.

3:03 p.m. Mrs. Smith says she's made a decision. She wants to do whatever Dr. Grumpy thinks she should do. Dr. Grumpy informs her that he is not going to do anything, as the TPA window has closed. Mrs. Smith asks Dr. Grumpy where she can get some sugar for her coffee.

53 comments:

I am a little scared of the TPA thing myself, I guess one should have that decision put in their medical directives if they can't speak, huh? I certainly don't want to rely on somebody else to make that decision for me either.

My dad walked into the hospital for an angiogram one day and ended up having a stroke during the procedure. Had TPA been available back then, his quality of life might have been much improved. As it turned out, they couldn't do anything for him. He died a year later in a nursing home from complications from the stroke. He never regained his left side, speech, or being able to eat.

After ECASS III I'd be happy for Dr Grumpy or any other competent Neurologist to give me TpA up to 4.5 hours after my ischaemic stroke. The thought of pre-hospital treatment with it makes my blood run cold. Give me scoop and run over paramedics staying and playing in almost any circumstances after an acute stroke.

You have the patience of a saint. I am talking to my husband tonight about this situation because he is also incapable of making decisions. I'm 25 now so hopefully by the time I need TPA he'll have made up his mind about it....

laughed about the Jeopardy part, but sad that it played out like this; not sure about the TPA administering, if I would want it or not, but sad that the wife couldn't quite get her act together to make a decision....

going to talk with hubby about this one so we can get our facts together sooner than later if either one of us want this treatment if offered down the road

Seriously, though, sometimes the decision should just be the doctor's from the get go. Give the person accompanying the patient a quick test, and if they prove to be an idiot, the doc takes it from there.

Patient's wife can't make critical decision, can't find anyone to make it for her, can't deal with the gravity of the situation so she finds something meaningless like coffee, and then it's all too late.(plus Dr. Grumpy humour)

You know, emergency room, husband sitting there in a semi-paralyzed state, frantic-looking doctors and nurses telling the wife, "Hurry up! You have just 5 minutes to decide whether to give this life-saving medication(*) to your husband!"

Suddenly, she sniffs the air a couple of times, looks around. The voices around her fade and become indistinct as she looks through a window and sees a Starbucks across the street. She gets up and follows the delicious smell of coffee to the Starbucks.

Final shot is of her back in the emergency room, blissfully drinking a Caramel Frappuccino, as her husband is toe-tagged and wheeled away.

I'm a nurse, so I sympathize with the wife and my heart aches for the husband. Life and death decisions on a timer are difficult at best and disastrous at worse. But that's life....how sad we in the medical field must harden our hearts d/t ignorance.

This type of procedure should be added to advance directives, in my opinion.

That is an amazing story, but not atypical I'm sure. My thoughts are(1) everybody get off your goddamm cell phones and pay attention to what's going on around you, (2) advance directives and living wills have been strongly recommended for years and all of a sudden it's become this ridiculous political football, and (3) I'm still waiting to see some intelligent panel discussions on health care reform -- perhaps featuring people like yourself who actually WORK in the trenches of health care and not some goofy ex-governors or radio talk show hosts.Oh, the frustration.... !!!!

Nice! Add in the extra 8+ min it takes the pharmacy to thaw the pre-made, sub zero frozen, TPA (which can be several if the patient is a big one)under their armpits or handing a syringe to everyone with hot hands! Loved the Jeopardy song over head idea. New to your blog...very amusing, indeed!~Pharmagirl

And in the end she still did not make a decision - "she wants to do whatever Dr. Grumpy thinks she should do." That is the part that kills me! I get that ALL THE TIME as a health care professional - informed consent does not mean I make the decision for you! YOU have to make the choice and deal with the consequences!

Mom and I wanted the doctors at my local, small, rural, county hospital to give my Dad the Clot Buster drug for his stroke. Instead, they wheeled him to a remote corner, and left him completely alone, to wait until the window of opportunity had passed before they would do anything at all, like a CAT scan. Then they said with impunity, "Oh, its to late for that."

If they had administered it when he first arrived at the hospital, three blocks away from our house, like Mom and I wanted them to; then Dad might still be alive.

They should have at least air lifted him to a larger hospital, that actually had a neurologist availiable for consultation, or on staff.

He had his stroke on Monday afternoon and died early Thursday morning, three years ago.

I think that the NINDS trial created one of the worst situations we as docs (and patients and their families) have to deal with. The study is not well done (and the new one that is now going to push the time frame to 4.5 hours is even weaker), and the in the years since I have been giving TpA, I am never really sure if the improvement patients had was due to the drug or just tinture of time (since many symptoms DO improve on their own), I DO however, remember the times patients have acutely bled and died! Add this to the fact that TpA issues are now one of the BIGGEST causes of lawsuits against ER docs and neurologists ("Why didn't you give it!" "Why did you give it!!") and I can tell you nothing makes us groan more than when the triage nurse yells "Acute CVA!!!" I actually often cross my fingers that the window has already closed.

I would, but we don't have half the drugs you have over here. I got my husband to read it, and he looked really grim, and said at least we knew we know what the other wanted - but whether we'd be offered it is a different matter...

I don't know. I do get that this play does not represent the ideal of informed medical decision making, even by an agent, even under stress and time pressure.

But come on. The "best" choice wasn't known. The wife had, presumably unexpectedly and with no advance preparation or information, to make a decision. Her seeking to inform their children and seek their input seems to me entirely appropriate (conceptually, if not practically). Dr. G., you yourself admits you don't know what the right answer was, but that you'd probably have chosen TPA. Could you have conveyed this more clearly to the patient's wife? She did make a decision, it wasn't (it seems) the one you'd have made, and if her mechanisms for making it seem less than perfect (and they do), well, it was a tough situation to be in.

In 2005 I was in the ER with my dad after he'd had a stroke and got the pros and cons of TPA. My dad was conscious, coherent, and able to communicate, but I had repeatedly to remind the resident that the decision was my dad's, not mine. In fact, we all agreed that TPA made sense and my dad took it; I assume it helped his recovery (it certainly didn't kill him, that much is clear).

Personally I'd say both based on my own experience and Dr. G's description that there's responsibility on both sides here ... the patient's (or agent's) to make a decision and the doctor to provide sufficient guidance to the person who has to make the decision. What's sufficient is going to vary widely depending on the people involved and I don't for a minute doubt that it's horrifically difficult, but still.

RioRN makes an excellent point. Whenever I get around to writing my advance directives (read: deciding what they actually are), I'll need to include TPA in there somewhere. I wonder if you can place a contingency in advance directives. If the phone a friend you've chosen is unavailable or unable to make a decision, default to care plan A. Don't let anyone else make it. There's some people I'd trust to make this decision. My current next of kin is not one of them.

@Masa with all due respect, what I see is that good clinicians agonize over just how directive to be (or not) and under what circumstances, that this issue is itself carefully studied and debated, and that no consensus has been reached on the "best" approach. I'd say the ideal is much more closely captured in this sentence than in what you write, "Informed decision making requires patients to understand the pros and cons of medical care and to have a say in what happens to them, especially for decisions that involve significant tradeoffs." (emphasis added; source is "Deficits and variations in patients' experience with making 9 common medical decisions: the DECISIONS survey." Zikmund-Fisher BJ, et. al., Med Decis Making. 2010 Sep-Oct;30(5 Suppl):85S-95S.

For another example, see "The role of doctor's opinion in shared decision making: what does shared decision making really mean when considering invasive medical procedures?" Mazur et. al. Health Expect. 2005 Jun;8(2):97-102 which, to summarize quickly, finds that (of 200 patients studied) 62.5% preferred sharing decision-making with the physician, 22.5% preferred physician-based, and only 15.5% preferred patient-based. More than half of all subjects chose physician opinion as the most important type of information for decision making.

If we pause to think through the logic of your assertion, it goes like this: Wife can understand and assess the risks and benefits associated with TPA having just been presented with them for the first time ever in a very stressful situation under time pressure.Yet in that same scenario, wife cannot understand that if she asks Dr. G. "What would you do?" and he replies, "This is such a difficult decision. On the one hand, there's a real risk of ... ; on the other hand, especially given your husband's negative CT, the available evidence suggests that TPA would benefit him. I think if I were in his shoes, I'd use the TPA, and I'd want it done as quickly as possible," that she cannot understand that he has just responded to a hypothetical question that isn't, literally, even a recommendation (much less an instruction).

I mean, I get it: what you should do depends on your preferences, and Dr. G's may be entirely different from the patient's. But to suggest that a patient's agent can make the decision about what to do in this case -- something that Dr. G. studied literally for years before he was considered qualified to do it on behalf of others -- but cannot distinguish between (e.g.) a recommendation and an instruction (or a response to a hypothetical and a response) strikes me as simply logically impossible. If she doesn't have the capacity to make that distinction, she doesn't have the capacity to learn and apply information about the risks and benefits associated with TPA.

Moreover, do we even know that the patient consented to having his wife act as his agent? I, to be honest, have been astonished by how carefree the medical institutions I interact with are, in this regard (my father has not given me a health care power of attorney, but I am routinely called upon to make medical decisions on his behalf when he is perceived, sometimes correctly and sometimes not, as being incapable of doing so.). Had this patient been delivered in an ambulance with no one else present and unable to communicate his wishes, would Dr. G. have refused to treat him at all (since no one was available to consent), or would he have done his best to make good decisions on the patient's behalf? If there was not in fact a clear directive (about who should make decisions when the patient cannot) did Dr. G. do the patient a service or a disservice in calling upon the wife to assume that role?

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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